Provider Demographics
NPI:1104052901
Name:PRIMARY SOURCE GROUP, PLLC
Entity type:Organization
Organization Name:PRIMARY SOURCE GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW, CSS
Authorized Official - Phone:919-434-3555
Mailing Address - Street 1:PO BOX 58098
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27658-8098
Mailing Address - Country:US
Mailing Address - Phone:919-434-3555
Mailing Address - Fax:919-981-7373
Practice Address - Street 1:4905 GREEN RD
Practice Address - Street 2:SUITE 105
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-2805
Practice Address - Country:US
Practice Address - Phone:919-981-7373
Practice Address - Fax:919-981-7373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1222101YA0400X
NC1572103T00000X
NC865103TC1900X
NCC0036631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106329Medicaid